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Business Systems Analyst Resume

MD

SUMMARY

  • Highly skilled and professional Sr. Business System Analyst with 7+ years of specific experience in the field of Healthcare (PAYER & PROVIDER).
  • Extensive knowledge of all phases of Software Development Life Cycle methodologies like Agile, Iterative Software Development and Waterfall Processes.
  • Experience in Requirements Elicitation: BRD, FRD, Use Cases, User Stories, EPICS, Acceptance Criteria and Data Scenarios.
  • Serves as liaison between the client and Development Team.
  • Responsible for gathering, analyzing, and documenting Business and Functional Requirements Documents
  • Understands the Business Rules and effectively implement them in Business Process Flow.( BPMN)
  • Thorough knowledge of object oriented analysis and design using UML diagrams such as Use Cases, Class Diagrams, State Diagrams and Flow Chart Diagrams.
  • Experience with compliant (e.g. HIPAA, 21 CRF Part 11) processes and operations development, Medicare and Medicaid
  • Worked on pharmacy billing and claims transmittal cycle through pharmacy benefit management (PBM) and Switch Vendors. This involves Receiving the prescription, gathering of patients data, data entry, pharmacy claims transmittal, third party claim adjudication, point of sale and payment processes.
  • Experienced in conducting and facilitating interviews, shadowing, brainstorming and Joint Application Development (JAD) sessions for Requirement Analysis, Risk analysis, Adaptability and Feasibility Studies with various stakeholders to identify business critical and high - risk areas of the application.
  • Experience in verifying EDI raw data of 837 transactions as per HIPAA based transactional 5010 formats and mandate.
  • Excellent working skills in FACETS and Claims Adjudications
  • Extensive experience in Gap analysis of HIPAA 4010 to HIPAA 5010 conversion using the implementation guide and companion guide of EDI transactions (EDI 837, EDI 835, EDI 834, EDI 820, EDI 270/271)
  • Good knowledge of ICD 9- CM, ICD 10-CM structures and differences
  • Sound experience in conducting Impact Analysis to migrate from ICD-9 to ICD 10 on the key business process and key application system like Claim Processing, Payments, and Reporting in the healthcare industry
  • Goal oriented professional with superior analytical, communication, presentation skills, excited and motivated to learn new technologies

TECHNICAL SKILLS

Business Modeling Tools: MS Visio/Visible Analyst

Processes: BPMN, Agile, Waterfall.

Requirements Management: IBM DOORS, JIRA

Data Modeling: UML, DOORS, JIRA.

Change Management: Rational ClearQuest

Management: MS Office Suite, MS Project, Excel

Databases: SQL Server

Data Quality: IBM Infosphere

Testing: ALM/QC, ClarEDI, Qualys

Claims Adjudication: Facets

PROFESSIONAL EXPERIENCE

Business Systems Analyst

Confidential, MD

Responsibilities:

  • Involved in Supporting BI and ETL Applications production jobs and changing existing code based on business needs.
  • Developed the scope and the vision document to define the primary goals, objectives & scope of the project (Hesnson Pharmacy Claim Process System)
  • Performed Gap Analysis, requirements analysis, impact analysis and validate requirements.
  • Extensively interacted with key stakeholders, SMEs, Development teams to finalize Business Requirement Document as in conjunction with CMS compliance and HIPAA regulations
  • Facilitated JAD sessions with management, Key stakeholders, development and user teams to gather and clarifying requirements
  • Performed Data Mapping and tested HIPAA EDI 5010 X12 mapping formats (such as 837,277,999, 835) as well as other industry standard and custom formats using ETL tools.
  • Worked on HIPAA 5010Trasactions sets 837P and 837I Standards as per test scenario
  • Created and managed Business Requirement Document (BRD), Functional Requirement (FRD) User Stories and Use Cases from requirement elicitations (Interviews, Brainstorming, Shadowing and JAD)
  • Responded to inquiries regarding EDI issues with enrollment, claims, payments, and/or clearinghouse activities. Conducts analysis of EDI transactions and documented reports.
  • Performed research and analytical role related to the claims adjudication system and internal processes.
  • Worked within a growing knowledge of ICD-834 (Benefit Enrollment), ICD-820 (Premium Payment),EDI processes, various ICD codes, Privacy, and Security (HIPAA 5010)
  • Provided mapping of data through exchanges of companion guides with Switch Vendors, Providers and Payers for efficient claim adjudication
  • Worked on Medicare Advantage (ABC) Medicare part D, Medicaid Options (Under 65 and over 65) Managed Care (Disease and Case Management, Insurance Regulations and Claims Processing and Claim Scrubbing in HMO, PPO, Medicare and Medicaid).
  • Experience in NCPDP rejection codes, DAW codes and POC codes for prescription drugs and refills.
  • Documented the Business and Functional requirements for designing the Billing System e.g. Cash management, Point of Sale (POS) module to enhance the encrypting standards that are required for the application
  • Performed complete reconciliation of Explanation of Benefit (EOB) and Explanation of Payment (EOP) and check remittances received from Managed Care contracts and send ICD-997/999 Functional Acknowledgment.
  • Worked closely with pharmacy technician in processing prescription intakes and Real Time Claim Adjudication(RTCA) for medication order entry and fill process based on CMS compliance for prescription origin code(POC) 0- 4
  • Validate the Business- to-Business(B2B) data exchanges between partners and validate the internal processing of Maintenance Management Information System(MMIS) or other transaction processing system though NCPDP Telecommunication VD.0 (835)
  • Provided mapping of data through exchanges of companion guides with Switch Vendors, Providers and Payers for efficient claim adjudication
  • Managed, owned the BRD and track development processes through Requirement Traceability Matrix.
  • Worked as an Interface between business users, testers and application development teams so that all users understood business needs and value
  • Involved in Incident Reporting and Change Control procedures to track changes during the development phase of the project

Environment: Waterfall/Agile, SQL Server 2012, MS Office (Word, PowerPoint, Excel), MS Visio, SharePoint, PBM, HP ALM/QC, JIRA

Business System Analyst/Scrum Master

Confidential, Newark DE

Responsibilities:

  • Performed Gap Analysis to evaluate the current state and future state and offer solutions to bridge the gap.
  • Assisted in the definition of done and the roll out of product roadmap (Spring Goal) across multiple releases by working with Product Owners and Development teams.
  • Planed and facilitated internal functional design sessions involving both business and technical resources through wireframes, documenting business rules and created high-level interface designs.
  • Serves as an escalation point to research and resolve data anomalies and mapping them to company requirements.
  • Led Sprint review sessions with both internal and external stakeholders and critically evaluate the Increment from multiple sources to develop logical recommendations.
  • Assisted Product Owner to create and prioritize User Stories to create value for users.
  • Often times serve as coordinator within the team as a Scrum Master Certified. (SMC)
  • Led User Acceptance Test (UAT) before the go-live of the product
  • Coordinated in conjunction with the Product Owner the overall timeline and operational readiness tasks for Sprint releases

Environment: Agile/Scrum, Waterfall, SQL Server 2012, MS Office (Word, PowerPoint, Excel), MS Visio, SharePoint, HP ALM/QC, JIRA

Program Planning and Evaluation Manager

Confidential, Hagerstown, MD

Responsibilities:

  • Spearheaded development of county diabetes registry to facilitate disease management and surveillance
  • Promote healthy lifestyles by researching, creating and leading numerous programs across diverse population.
  • Identify and increase participation of target minority ethnic populations for diabetes management from 30% to 55% within 3 months of engagement.
  • Researched diabetes health related problems and formulated pragmatic policies to address them.
  • Promoted smoking cessation outreach programs from 20% to 50% within 6 months of engagement among cross-functional demographics.
  • Developed diverse outreach materials for health promotions such as flyers, brochures and PowerPoint presentation for tobacco cessation programs.
  • Gathered primary data, reviewed and analyzed child fatalities in Washington County within 1 month for the Fatality Review Committee.
  • Monitored and evaluated outcomes of the diabetes registry and recommendations for its adoption by the Health Council of Washington County.
  • Developed and implemented Individual Personal Goals, counseling services for behavior modification and community integration plans for physically and mentally challenged residents.
  • Delivered health education on issues of safe sex, smoking cessation physical activities and behavioral risk factors.
  • Offered crisis interventions management to vulnerable clients to prevent intentional harm and ensure residence safety for DDA programs.
  • Provided strategies and awareness among the staff for teamwork, efficient communication channels and good work ethics.

Environment: Waterfall, Agile/Scrum, SQL Server 2008, MS Office (Word, PowerPoint, Excel)

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